Emergency endotracheal intubation and especially emergency endotracheal intubation in the trauma setting with possible cervical spine injury have a significantly high complication rate. Not only are these patients frequently unstable and thus making the need for rapid intubation crucial; but the conditions in the field and the experience of the persons performing the intubation are certainly less optimal than in the operating room setting.
Complications of endotracheal intubation are numerous and frequent In one study, 38 complications occurred in 24 of 43 patients requiring emergency room endotracheal intubation. Complications include aspiration, interruption of CPR (cardiopulmonary resuscitation), prolonged period required for intubation, right mainstem bronchus intubation, tube damage during insertion, and pneumothorax (an accumulation of air or gas in the pleural space). In another study, nearly one-third of all endotracheal intubations took over two minutes, and one fifth required four or more attempts. For standard orotracheal intubation with the neck extended, a curved or flat larynogoscope is used to visualize the vocal cords during tube insertion. Thus, the present situation of orotracheal or nasotracheal intubation has room for improvement.
The esophageal gastric tube airway is infrequently used now, but in the past was used regularly by emergency room technicians. This device is inserted blindly into the esophagus The advantage is the ease of insertion and that no special training is required The disadvantage is that the ventilation is much less efficient than with the endotracheal tube. In one study, the esophegeal gastric airway provided blood gas on an average pH of 7.12, p02 of 77, pC02 of 78, while the endotracheal tube produced pH of 7.34, p02 of 265 and pC02 of 35.
Other techniques include the optical stylet and fiberoptic bronchoscope. These methods use either the rigid stylet or the flexible bronchoscope to visualize the vocal cords, and the endotracheal tube is inserted under direct visual guidance.
Invasive techniques include percutaneous jet ventilation, cricothyroidotomy, and emergency tracheostomy. Jet ventilation requires insertion of a catheter into the trachea through the cricothroid membrane, and with rapid ventilation, can provide excellent respiratory support but for only limited periods of time, about one hour. Cricothyroidotomy may be performed with relative ease and rapidity by inserting a blade into the neck through the cricothroid membrane. This method is easily learned but has increased risk of tracheal stenosos over the standard tracheostomy. Although cricotyroidotomy is hardly a method for routine use to provide an airway in the trauma patient, it is very useful in selected patients. Emergency tracheostomy is certainly an excellent means of obtaining ventilatory support for a patient, but has many risks in the emergency setting, can be very difficult and requires a great deal of training. Therefore, it is not suitable for emergency endotracheal intubation. Finally retrograde endotracheal intubation over a guide wire is performed by piercing the cricothroid membrane with a needle, then advancing a flexible wire up through the trachea and vocal cords and out the mouth, and then placing the endotracheal tube over the wire and guiding it into the trachea. This method is very useful for difficult endotracheal intubations, but requires special training, special equipment and an invasive technique. Therefore, there are many alternatives to standard orotracheal intubation which can be used in emergency intubations or especially in emergency intubations in the trauma setting, but each requires specialized training and/or equipment not routinely available to emergency workers. Additionally, many of these methods require manipulation of the neck which may be contradicted in trauma patients, and each technique has a long list of complications.